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Erenberg M, Rotem R, Segal D, Yohay Z, Idan I, Yohay D, Weintraub AY. Adhesion barriers and topical hemostatic agents are risk factors for post-cesarean section infections. Surgery 2021; 170:1120-1124. [PMID: 33933281 DOI: 10.1016/j.surg.2021.03.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 03/15/2021] [Accepted: 03/22/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Cesarean sections are the most common surgery worldwide, and post-cesarean section infections and hemorrhage are a major cause for morbidity and mortality. In recent years, many surgeons use adhesion barriers as well as hemostatic agents during primary and repeated cesarean section. The data regarding the safety of these agents is relatively limited. The objective of this study was to investigate whether the use of adhesion barriers and topical hemostatic agents pose a risk for post-cesarean section infections. METHOD A case-control study composed of women who were admitted to the Soroka University Medical Center between the years 2012 and 2016 was conducted. The study group was composed of women admitted owing to post-cesarean section infections (cases) and those who underwent cesarean sections without post-cesarean section infection (control subjects). Matching was done according to date and surgery setting (elective versus emergency). A univariate analysis was followed by a multiple regression model in order to examine the association between adhesion barriers/hemostatic agents and post-cesarean section infections. RESULTS During the study period, 113 patients developed postoperative infection (cases); 71.7% were diagnosed with surgical site infection, 7.1% with endometritis, and 21.2% with other infections. These were compared with 226 control subjects. In the univariate analysis, the use of adhesion barriers/hemostatic agents were found to be associated with post-cesarean section infection. Using a multivariable analysis controlling for previous cesarean section, skin closer technique, preterm delivery, and duration of surgery >60 minutes, the use of adhesion barriers as well as hemostatic agents was found to be independently associated with post-cesarean section infection (adjusted odds ratio = 2.11, 95% confidence interval = 1.17-3.84; adjusted odds ratio = 2.29, 95% confidence interval = 1.37-3.8, respectively) CONCLUSION: Adhesion barriers and hemostatic agents were found to be independently associated with post-cesarean section infections. Further larger studies are needed to reinforce our findings. The use of these materials should be carefully considered, and their cost-effectiveness re-examined.
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Affiliation(s)
- Miriam Erenberg
- Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
| | - Reut Rotem
- Obstetric and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University Medical School of Jerusalem, Israel
| | - David Segal
- Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Zehava Yohay
- Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Inbal Idan
- Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - David Yohay
- Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Adi Y Weintraub
- Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Rottenstreich M, Rotem R, Hirsch A, Farkash R, Rottenstreich A, Sela HY, Samueloff A, Grisaru-Granovsky S. The use of absorbable adhesion barriers to reduce the incidence of intraperitoneal adhesions at repeat cesarean delivery. Arch Gynecol Obstet 2020; 302:101-108. [PMID: 32415470 DOI: 10.1007/s00404-020-05591-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 05/05/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE We aimed to evaluate the effect of an absorbable adhesion barrier (oxidized regenerated cellulose) for the prevention of peritoneal adhesions in women undergoing repeat cesarean delivery (CD). METHODS This is a retrospective, single center study that included all women who underwent two consecutive CDs, 2011-2018. Women in whom an absorbable adhesion barrier (oxidized regenerated cellulose) was placed at the time of the initial CD (index CD) were compared to women in whom no such barrier was placed. The association between absorbable adhesion barrier placement at index CD and the presence of intraperitoneal adhesions at subsequent CD was assessed. Factors evaluated included intraperitoneal adhesion severity, time from skin incision to newborn delivery and total duration of surgery. RESULTS We identified 2125 women that met the inclusion criteria. They were divided into two groups; those in whom an absorbable adhesion barrier was placed at index CD and those in whom no such absorbable barrier was placed. 161 (7.6%) had an absorbable adhesion barrier placed at index CD. At the time of index CD, the rate of intra-peritoneal adhesions was 34.8% in the absorbable adhesion barrier group vs 26.5% in the group without the absorbable adhesion barrier (p = 0.02). At the time of subsequent CD, the rate of intraperitoneal adhesions was 39.8% in the absorbable adhesion barrier group vs 46% in the group without the absorbable adhesion barrier (p = 0.13). Notably, the use of an absorbable adhesion barrier lowered the mean increase in adhesions rate 0.05 ± 0.55 vs 0.20 ± 0.55 (p < 0.01). Absorbable adhesion barrier placement at index CD was found to be independently associated with a lower rate of intraperitoneal adhesions at subsequent CD, aOR 0.67 (0.47-0.96). Overall, absorbable adhesion barrier placement at index CD was associated with a shorter mean duration of subsequent surgery (min), 37.7 ± 18.9 vs. 42.7 ± 27.1 (p = 0.02). CONCLUSION Absorbable adhesion barrier placement is associated with reduction in intraperitoneal adhesions and duration of surgery in subsequent CD.
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Affiliation(s)
- Misgav Rottenstreich
- Department of Obstetrics and Gynecology, 12 Bayit Shaare Zedek Medical Center, Affiliated with the Hebrew University School of Medicine, 91031, Jerusalem, Israel.,Department of Nursing, Jerusalem College of Technology, Jerusalem, Israel
| | - Reut Rotem
- Department of Obstetrics and Gynecology, 12 Bayit Shaare Zedek Medical Center, Affiliated with the Hebrew University School of Medicine, 91031, Jerusalem, Israel.
| | - Ayala Hirsch
- Department of Obstetrics and Gynecology, 12 Bayit Shaare Zedek Medical Center, Affiliated with the Hebrew University School of Medicine, 91031, Jerusalem, Israel
| | - Rivka Farkash
- Department of Obstetrics and Gynecology, 12 Bayit Shaare Zedek Medical Center, Affiliated with the Hebrew University School of Medicine, 91031, Jerusalem, Israel
| | - Amihai Rottenstreich
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Hen Y Sela
- Department of Obstetrics and Gynecology, 12 Bayit Shaare Zedek Medical Center, Affiliated with the Hebrew University School of Medicine, 91031, Jerusalem, Israel
| | - Arnon Samueloff
- Department of Obstetrics and Gynecology, 12 Bayit Shaare Zedek Medical Center, Affiliated with the Hebrew University School of Medicine, 91031, Jerusalem, Israel
| | - Sorina Grisaru-Granovsky
- Department of Obstetrics and Gynecology, 12 Bayit Shaare Zedek Medical Center, Affiliated with the Hebrew University School of Medicine, 91031, Jerusalem, Israel
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Plante B, Sukalich S, Elliott JO. Adhesion Assessment at First Repeat Caesarean Section With or Without Prior Adhesion Barrier Use. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 38:795-803. [DOI: 10.1016/j.jogc.2016.06.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 05/05/2016] [Indexed: 11/15/2022]
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Kiefer DG, Muscat JC, Santorelli J, Chavez MR, Ananth CV, Smulian JC, Vintzileos AM. Effectiveness and short-term safety of modified sodium hyaluronic acid-carboxymethylcellulose at cesarean delivery: a randomized trial. Am J Obstet Gynecol 2016; 214:373.e1-373.e12. [PMID: 26478104 PMCID: PMC4818004 DOI: 10.1016/j.ajog.2015.10.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 10/04/2015] [Accepted: 10/09/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND The rising cesarean birth rate has drawn attention to risks associated with repeat cesarean birth. Prevention of adhesions with adhesion barriers has been promoted as a way to decrease operative difficulty. However, robust data demonstrating effectiveness of such interventions are lacking. OBJECTIVE We report data from a multicenter trial designed to evaluate the short-term safety and effectiveness of a modified sodium hyaluronic acid (HA)-carboxymethylcellulose (CMC) absorbable adhesion barrier for reduction of adhesions following cesarean delivery. STUDY DESIGN Patients who underwent primary or repeat cesarean delivery were included in this multicenter, single-blinded (patient), randomized controlled trial. Patients were randomized into either HA-CMC (N = 380) or no treatment (N = 373). No other modifications to their treatment were part of the protocol. Short-term safety data were collected following randomization. The location and density of adhesions (primary outcome) were assessed at their subsequent delivery using a validated tool, which can also be used to derive an adhesion score that ranges from 0-12. RESULTS No differences in baseline characteristics, postoperative course, or incidence of complications between the groups following randomization were noted. Eighty patients from the HA-CMC group and 92 controls returned for subsequent deliveries. Adhesions in any location were reported in 75.6% of the HA-CMC group and 75.9% of the controls (P = .99). There was no significant difference in the median adhesion score; 2 (range 0-10) for the HA-CMC group vs 2 (range 0-8) for the control group (P = .65). One third of the HA-CMC patients met the definition for severe adhesions (adhesion score >4) compared to 15.5% in the control group (P = .052). There were no significant differences in the time from incision to delivery (P = .56). Uterine dehiscence in the next pregnancy was reported in 2 patients in HA-CMC group vs 1 in the control group (P = .60). CONCLUSION Although we did not identify any short-term safety concerns, HA-CMC adhesion barrier applied at cesarean delivery did not reduce adhesion formation at the subsequent cesarean delivery.
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Affiliation(s)
- Daniel G Kiefer
- Department of Obstetrics and Gynecology, Lehigh Valley Health Network, Allentown, PA; Department of Obstetrics and Gynecology, Winthrop University Hospital, Mineola, NY; Department of Obstetrics, Gynecology, and Reproductive Medicine, Stony Brook University, Stony Brook, NY.
| | - Jolene C Muscat
- Department of Obstetrics and Gynecology, Winthrop University Hospital, Mineola, NY
| | - Jarrett Santorelli
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Stony Brook University, Stony Brook, NY; Department of Surgery, University of Buffalo, Buffalo, NY
| | - Martin R Chavez
- Department of Obstetrics and Gynecology, Winthrop University Hospital, Mineola, NY
| | - Cande V Ananth
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - John C Smulian
- Department of Obstetrics and Gynecology, Lehigh Valley Health Network, Allentown, PA
| | - Anthony M Vintzileos
- Department of Obstetrics and Gynecology, Winthrop University Hospital, Mineola, NY
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Bolnick A, Bolnick J, Diamond MP. Postoperative Adhesions as a Consequence of Pelvic Surgery. J Minim Invasive Gynecol 2015; 22:549-63. [DOI: 10.1016/j.jmig.2014.12.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 12/05/2014] [Accepted: 12/08/2014] [Indexed: 01/12/2023]
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Adhesion prevention after cesarean delivery: evidence, and lack of it. Am J Obstet Gynecol 2014; 211:446-52. [PMID: 24858198 DOI: 10.1016/j.ajog.2014.05.027] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 05/20/2014] [Indexed: 11/21/2022]
Abstract
In spite of the recognized occurrence of cesarean-attributable adhesions, its clinical significance is uncertain. The presence of adhesions during a repeat cesarean section can make fetal extraction lengthy and the procedure challenging and may increase the risk of injury to adjacent organs. Two methods for adhesion prevention are discussed, peritoneal closure and use of adhesion barriers. Peritoneal closure appears to be safe in the short term. In the long term, conflicting evidence arise from reviewing the literature for possible adhesion reduction benefits. A systematic review of the literature on the use of adhesion barriers in the context of cesarean section yielded only a few studies, most of which are lacking in methodology. For now, it appears that the available evidence does not support the routine use of adhesion barriers during cesarean delivery.
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Cesarean Delivery Times and Adhesion Severity Associated With Prior Placement of a Sodium Hyaluronate-Carboxycellulose Barrier. Obstet Gynecol 2014; 124:679-683. [DOI: 10.1097/aog.0000000000000450] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Edwards RK, Ingersoll M, Gerkin RD, Bodea-Braescu AV, Lin MG. Carboxymethylcellulose Adhesion Barrier Placement at Primary Cesarean Delivery and Outcomes at Repeat Cesarean Delivery. Obstet Gynecol 2014; 123:923-928. [DOI: 10.1097/aog.0000000000000220] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Li WY, Liabsuetrakul T, Stray-Pedersen B. Effect of mode of delivery on perceived risks of maternal health outcomes among expectant parents: a cohort study in Beijing, China. BMC Pregnancy Childbirth 2014; 14:12. [PMID: 24410828 PMCID: PMC3898524 DOI: 10.1186/1471-2393-14-12] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Accepted: 01/09/2014] [Indexed: 12/22/2022] Open
Abstract
Background Misperceptions regarding maternal health outcomes after vaginal delivery (VD) and cesarean delivery (CD) may contribute to the increasing trend towards CD. The effects of mode of delivery on parents’ perceived risks of health outcomes are unclear. This study aimed to compare the perceived risks of maternal health outcomes among pregnant women and their partners before and after delivery, and to evaluate factors related to inaccurate perceptions among women after delivery. Methods Consecutive eligible nulliparous women at 36-40 weeks gestation were approached during antenatal registration for electronic fetal monitoring, regardless of whether CD or VD was planned. Eligible women were aged 18-45 years, received antenatal care and planned delivery at the First Hospital of Tsinghua University, Beijing, and had partners who could be approached. Concerns about 12 maternal health outcomes were identified by literature search and validated using the content validity index. Women and their partners were questioned anonymously about the perceived risks of outcomes after CD and VD before delivery, and the perceived risks of the delivery experienced at 2-3 days after delivery. Perceived risks were compared with reported risks, and factors associated with inaccurate perceptions were evaluated. Results Among 272 couples approached, 264 women (97%) and 257 partners (94%) completed the questionnaire both before and after delivery. After CD, the perceived risk of seven health outcomes decreased in women and the perceived risk of two health outcomes increased in partners. After VD, the perceived risk of two outcomes decreased and of one outcome increased in women, and the perceived risk of three outcomes increased in partners. Women perceived higher risks of long-term perineal pain, pelvic organ prolapse, urinary/fecal incontinence, sexual dissatisfaction, and negative impact on the couple’s relationship after VD than after CD (all p < 0.05). CD was the most common factor associated with inaccurate perceptions among women after delivery. Conclusions The perceived risks of maternal health outcomes decreased after delivery in women and increased after delivery in their partners. Women continued to have inaccurate perceptions of the risks of health outcomes after delivery, indicating that further education is important.
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Affiliation(s)
- Wen-Ying Li
- Department of Obstetrics and Gynecology, First Hospital of Tsinghua University, Tsinghua University, No, 6 Jiuxianqiao 1st Street, Beijing 100016, Chaoyang District, China.
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Dietrich A, Bouzidi M, Hartwig T, Schütz A, Jonas S. Rapamycin and a hyaluronic acid-carboxymethylcellulose membrane did not lead to reduced adhesion formations in a rat abdominal adhesion model. Arch Gynecol Obstet 2012; 285:1603-9. [DOI: 10.1007/s00404-011-2184-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Accepted: 12/14/2011] [Indexed: 11/28/2022]
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